I woke up to the sound of a shrill female voice giggling its way through boozy conversation. It was still dark, early Tuesday morning. I checked my phone, oy, 3:30. This was not the first time that Dallas’ Uptown scene decided to grace the pool outside our window with its exuberance at an uncivilized hour of the morning. I rolled over several times in an effort to get comfortable. When that failed, my senses heightened from sleep and I became aware of an odd pain in my belly. It had a dull, cramping quality and was located in a horizontal band beneath my belly button. Strange. As I tried to shut out the sound of the inane conversation, the pain squeezed on.
I should pause to say that I’m very fortunate to enjoy vigorous good health. My good luck with my own health combined with some experience seeing what can go wrong have made me a firm believer that the best treatment for sickness is to stay healthy in the first place. I rarely have illnesses, and when I do, I tend to get over the symptoms and get back to myself in short order. The body really is a miraculous thing, baruch hashem, as they say.
This was a strange pain, different in quality from what I had experienced before. Staring up at the whirling ceiling fan, I started to consider self-diagnostic possibilities. I figured that I was coming down with a touch of gastroenteritis. Working with kids in the hospital usually means that I get to experience this once or twice a year. I attempted to palpate my abdomen, wondering how sensitive this maneuver can be (maybe something like trying to tickle oneself?). I was pretty sure that I did not have a surgical abdomen. I felt a little nauseous (consistent with my gastro hypothesis, right?). I figured I would poop my brains out, maybe puke, and then I would feel much better. I made an unproductive attempt at vomiting, nothing happened on the throne. Odd. By 8:30 the pain was no better, maybe a little worse: constant, dull periumbilical abdominal pain. Really, I started to think, appendicitis?
My time in the pediatric ER as a resident conditioned me to have appendicitis at the top of my diagnostic working list (known in the business as the “differential diagnosis”) for kids with abdominal pain. I quickly became accustomed to ordering complete blood counts (CBCs), sending kids for abdominal CT scans, and giving the surgeon-on-call an FYI text page (we can wonder another time about why doctors still use pagers). It turns out that the peak incidence of appendicitis is in kids age 10 to 19 (233 cases in 100,000 individuals), but is also higher in the “third decade” (which I am close to but no longer part of). The appendix is a narrow, finger-like outpouching of bowel that extends off of the cecum, where the small intestine and the colon meet in the right, lower portion of the abdomen. The appendix appears to have no physiological purpose, only its pathologic purpose of becoming obstructed and inflamed in appendicitis. This vestigial organ’s function was lost at some ancient juncture, an apply named appendix to the story of our species’ evolutionary history. The classic presentation involves right lower quadrant pain, fever, and an elevated white blood count. I guessed that I would be 0 for 3, but had also learned that in the early stages, appendicitis often causes vague pain centered around the belly button and that the signs of systemic inflammation (fever, elevated white count) are not always present.
I figured that I would need to wake up my wife, Robin, and ask her to take me to the emergency room. First, I thought it prudent to talk things over with my good friend Matt, emergency physician and pulmonologist par excellence, the guy who I would want to be my doctor if he would have me as a patient. I half expected him to propose an obvious and trivial explanation for my symptoms and tell me to get in the shower and go to work. Instead, he responded, “Okay, where were you thinking of going?” We discussed logistics and after getting freshened up and groomed, Robin and I headed out to my medical school’s university hospital emergency room.
One of the clinical pearls (old-school medical wisdom passed on in prophetic tones from the experienced to the green) regarding appendicitis is that patients have increased pain when they are jostled in the car on their trip to the ER. A skilled practitioner can even simulate this “test” by accidentally knocking into the bed, causing vibration to agitate the inflamed appendix in the patient’s abdomen and the patient to wince. It was not agonizing, but I definitely felt every bump, concrete seam, and pothole of Lemmon Ave. as we made our way west.
No one will tell you that morning, after shift change, is the best time to go to an emergency room, say around 8 or 9 AM. The new crew came in at 7AM, had a chance for their coffee to kick in and to start clearing out the backlog of overnight patients waiting to move upstairs up to the floor or to have results return before they can be sent home. We strolled in just towards the end of the morning sweet spot and the waiting room was nearly empty. There was a Caucasian woman in her early 40s in a wheelchair clutching a vomit bucket, a Hispanic man of about 60 with no obvious medical condition and a jovial look, and me. The intake nurse typed my social security number into the system as she arranged the cuff to take my blood pressure. I’m a little ashamed to admit that I had my hospital ID clearly visible on my lap as she did the intake. She asked me if I worked there. I explained that I was a fellow at the Children’s hospital. The white bracelet that she snapped on my right wrist a few moments later included the words, “Unidentified Physician.”
We were directed to an exam room that was spacious but showing its age. Robin managed to sort out the complicated hospital gown, snapping and tying up the back. Earnest staff came in to collect my insurance card, draw some blood, and place an IV. Matt knocked on the door, briefly examined my belly, and took a seat next to Robin. The next knock singled the arrival of a radiology technician who announced that she was going to take me to have chest and abdominal X-rays. I shared a quizzical look with Matt. There really was not an indication for the X-rays. My symptoms were not consistent with a bowel obstruction or perforation and an X-ray would not shed any light on the question of whether or not I had appendicitis. I did my best to adopt an apologetic tone and asked if I could possibly see the doctor before having the tests done so that we could talk it over first. No problem, the technician promptly retreated. Matt stewed that the tests were ordered before I was properly evaluated.
Next, a tall African American woman entered and identified herself as a physician’s assistant working with the ER doctor. I gave her my already well-rehearsed account of the morning’s events. She asked me questions about my health history. She gently pushed on my belly and saw that I did not have peritonitis, diffuse inflammation of the abdomen that would have sent her out of the room in a hurry to call the surgeons. She announced that we would do the CT scan with oral and IV contrast and that the technicians would be in shortly to get things underway. We thanked her. The oral contrast was purple and vaguely strawberry flavored. I would choose this in a second over Go-lightly bowel prep, the contrast is superior in both taste and texture. Robin could not resist snapping a fetching picture of me raising a Styrofoam glass. Bottoms-up!
A half hour later, I held my breath for a few seconds as the table moved in and out of the donut-shaped ring of detectors. The slick 64-channel high-resolution CT machine had a window in its housing where red lights showed the rotation of the detector array. Directly above on the ceiling, the standard plastic shade for the incandescent bulbs had been replaced with puffy white clouds in a blue sky. Nice touch.
I had been sleeping for about an hour when the doctor knocked and rolled in. He was in his fifties, grey hair, long on the sides and in the back. He wore black boots, black jeans, silver belt ornaments, and a black leather vest over a black button down shirt. He had a stethoscope around his neck and his vest and pockets held either more tools of the trade or some magic tricks. He looked like what Tom Petty might have become if he had gone to medical school. Dr. Black Vest was up-energy and pleasant. Drowsy, I gave him a bullet-point run down on my pain. He asked a couple of follow-up questions, pulled up my gown and examined my abdomen. He applied gentle pressure at a few spots, include the key spot in the right lower quadrant known as McBurney’s point, where the appendix usually lives. It was just a little uncomfortable, he could tell from my reaction. Straightening and taking a step back, he let us know that the lab tests were normal, and that the radiologist’s read was that that CT was also normal. He then started to make small talk about the places he had worked, about the ER at our Children’s hospital, about unusual cases of appendicitis that he had seen. He asked me about my fellowship program and pediatric rheumatology, making a self-effacing remark that I must be “one of those smart doctors.” He asked me if the staff had treated me nicely and if I needed anything for pain. I told him that I would be happy to head home, give things some time, and that we would be sure to come back if something was not right. Before stepping out, he told us that he would personally review the CT images and that he would be back if he did not agree with the radiologist, otherwise, we wouldn’t see him again. Robin and I both thanked him. I don’t think that we shook hands.
About four hours had passed since we hit the door of the ER. Robin had been very patient throughout the waiting and was ready to go home and eat lunch. I was happy to make the transformation back from patient to guy in jeans and a T-shirt. I slept for most of the afternoon. That evening my appetite came back and the pain seemed to be gone. This time at around 2:30 AM, I was bolt awake. The pain was back, same location, same quality. I thought back to my conversation with Matt, headed downstairs, took a Zantac and washed it down with the remaining pink liquid from a bottle of Pepto. It did the trick and I had my diagnosis – gastritis. It seems that my stomach was either over-producing acid and/or had become overly sensitive to the acid level. With this came reflux, acidic stomach contents heading up the wrong way into the lower part of the esophagus. Unfortunately, I passed a couple more painful nights of tossing and turning, but it seems that the acid suppression strategy has worked. With luck, this episode of gastritis is behind me.
I feel a little foolish that my appy ended up being a scrape with acid reflux. Like many doctors, I’m a minimalist when it comes to my own health care (in my case, this carries over to my patients as well). While we waited in the ER, Matt told me a story of a colleague of his whose appendix had been ruptured for a couple of days before he finally allowed himself to be taken to the hospital. It was good to go, have things checked out, and at the end of the day, to have good news. Being reminded of the fear, uncertainty, impatience, and discomfort that we all experience as patients was a bonus takeaway.